1. Field of the Invention
The present invention is related to decision making for cost effectiveness in medical treatment, and more particularly related to an algorithmic method for generating a medical utilization profile for a patient to thereby facilitate medical risk decisioning.
2. Description of the Prior Art
The following 12 patents and published patent applications are the closest prior art references which are related to the present invention.    1. U.S. Pat. No. 5,970,463 issued to Douglas G. Cave et al. and assigned to Practice Patterns Science, Inc. on Oct. 19, 1999 for “Medical Claims Integration And Data Analysis System” (hereafter the “Cave Patent”);    2. U.S. Pat. No. 6,223,164 issued to Jerry G. Seare et al. and assigned to Ingenix, Inc. on Apr. 24, 2001 for “Method And System For Generating Statistically-Based Medical Provider Utilization Profiles” (hereafter the “'164 Seare Patent”);    3. U.S. Pat. No. 6,266,645 issued to Kit N. Simpson and assigned to iMetrikus, Inc. on Jul. 24, 2001 for “Risk Adjustment Tools For Analyzing Patient Electronic Discharge Records” (hereafter the “Simpson Patent”);    4. U.S. Pat. No. 6,370,511 issued to Dennis K. Dang and assigned to Symmetry Health Data System, Inc. on Apr. 9, 2002 for “Computer-Implemented Method For Profiling Medical Claims” (hereafter the “Dang Patent”);    5. U.S. Pat. No. 6,802,810 issued to Anthony Ciarniello et al. and assigned to Active Health Management on Oct. 12, 2004 for “Care Engine” (hereafter the “Ciarniello Patent”);    6. United States Published Patent Application No. 2006/0020466 to Leo E. Cousineau et al. on Jan. 26, 2006 for “Ontology Based Medical Patient Evaluation Method For Data Capture And Knowledge Representation” (hereafter the “Cousineau Published Patent Application”);    7. United States Published Patent Application No. 2006/0052945 to Matthew Rabinowitz et al. on Mar. 9, 2006 for “System And Method For Improving Clinical Decisions By Aggregating, Validating And Analysing Genetic And Phenotypic Data” (hereafter the “Rabinowitz Published Patent Application”);    8. United States Published Patent Application No. 2006/0074712 to Kelly R. Jorgensen et al. on Apr. 6, 2006 for “Systems And Methods For Supplying A Useful Collection Of Medical Coding Data” (hereafter the “Jorgensen Published Patent Application”);    9. U.S. Pat. No. 7,127,407 issued to Richard Francis Averill et al. and assigned to 3M Innovative Properties Company on Oct. 24, 2006 for “Method Of Grouping And Analyzing Clinical Risks, And System Therefor” (hereafter the “Averill Patent”);    10. U.S. Pat. No. 7,209,923 issued to Richard G. Cooper on Apr. 24, 2007 for “Organizing Structured And Unstructured Database Columns Using Corpus Analysis And Context Modeling To Extract Knowledge From Linguistic Phrases In The Database” (hereafter the “Cooper Patent”);    11. U.S. Pat. No. 7,222,079 issued to Jerry G. Seare et al. and assigned to Ingenix, Inc. on May 22, 2007 for “Method And System For Generating Statistically-Based Medical Provider Utilization Profiles” (hereafter the “'079 Seare Patent”); and    12. United States Published Patent Application No. 2007/0130206 to Xiang Zhou et al. on Jun. 7, 2007 for “System And Method For Integrating Heterogeneous Biomedical Information” (hereafter the “Zhou Published Patent Application”).
The Cave Patent discloses a medical claim integration and data analysis system. Although the invention is focused on application to the medical claims, the invention is also intended to solve problems including: “some of which (claims) have principal diagnosis codes, some of which have non-principal, missing, or incorrect diagnosis codes” (Abstract). In addition, the ICD.9 code is indicated by the Cave Patent as one of the principal diagnosis codes that the invention is targeted on analysis (column 8, line 27, continued to column 9, line 12). For diagnosis of the ICD. 9 code, the invention applies the mapping technique (column 8, lines 43 to 44), which is one of the classification methods to identify interests of study.
There are some very clear differences in the technical approach that Cave takes from the present application algorithm:
1. The Cave Patent abstract states: “A diagnosis cluster lookup table enables claim items to be categorized into PTEs with ongoing treatment windows for which the diagnosis code of the claim item is in the diagnostic cluster look up table”. This is actually a completely different approach the present invention. The present invention uses ontologies which, in the context of comparison to lookup tables, can render results much faster (and therefore be more scalable in real-life systems that have massive amounts of data) and can provide non-linear interpolative results for gaps that may exist in the data. The combination of ontologies and reasoners can also be considered self-learning as introduction of additional data can yield new unintended inferences.
2. The independent variables recognized in the Cave Patent are limited to patient treatment information. The present invention algorithm incorporates a wider base of independent variables which can in turn yield a significantly more accurate result.
The Seare Patent is a method and system for generating statistically based medical provider utilization profiles. The invention is to provide a method for comparing profiles, particularly for comparing index codes including the ICD-9 code against historical reference information such as the historical medical provider billings.
The Simpson Patent is a risk adjustment tool for analyzing patient electronic discharge records through a selective extraction procedure. In the procedure, the content of the discharge records is matched against one or more “key explanatory variables” such as a “selection vector” which is a collection of patient codes including the ICD.9 code that implicitly specify the condition of interest.
The Dang Patent is a computer-implemented method for profiling medical claims to assist health care managers in determining the cost-efficiency and service quality to health care providers. The objective is for measuring and qualifying health care service based upon medical episode treatment groups.
The Ciarniello Patent offers a comprehensive solution to care management. The invention offers including (1) application tools for identifying potentially problematic patient cases, (2) case and disease management applications and programs for managing problematic and complex cases and (3) applications and services to improve overall risk underwriting profitability. The invention aggregates, integrates and stores clinical information from disparate sources through providing an example of analysis using a hypothetical patient, Jane (column 6, line 32 continued to column 7, line 12). In the analysis, the Patent discloses that through comparison of her available lab, prescription and claims data, it finds the drug Glucophage which is not recommended. Through this example, it is clear that the Ciarniello Patent does not apply statistical methods in the analysis, as compared with your invention.
The Cousineau Published Patent Application discloses an ontology based medical patient evaluation method for data capture and knowledge representation. It specifically discloses two key processing steps: (1) the syntax and (2) ontology processing step. From application of the invention, non standard input data can be converted into the standardized output data. The Cousineau Patent states: “In one embodiment, the invention provides a patient evaluation method wherein non-standard input data is received in a syntax processing block and a corrected data file is generated in relation to a healthcare lexicon.” Therefore, the focus of the Cousineau's Patent is to clean up the input for further processing by some other system.
Nearly all of the other claims of the Cousineau Patent focus on the method of collection of data (such as voice, through a wireless network, etc.) where the ontology techniques are used for organization and clean up of the data. There is no mention of usage of reasoners, application of stochastic, statistic, or other mathematical techniques to help provide a viable risk model, and finally no specification of key independent variables required to construct such model.
The Rabinowitz Published Patent Application is focused on applying statistical methods to aggregate, validate and analyze genetic and phenotypic data for caregivers to make better decisions. The Patent Application discloses including the regression method to statistically treat data (Paragraph [0205]). In addition, from using the statistical Model Expert 301 and 302 “the data can be automatically inhaled into the standardized ontology, and can be acted upon by the published training and mapping functions . . . ” (Paragraph [0211]).
The Jorgensen Published Patent Application discloses a system and method for supplying a useful collection of medical coding data, which does not apply the ontology and set theory.
The Averill Patent creates a comprehensive set of risk groups which in particular explicitly identifies groups of individuals with multiple interacting co-morbid conditions, and which explicitly identifies the severity of illness level. The invention includes application of the ICD-9 codes to establish Major Disease Categories (MDCs).
The Cooper Patent illustrates how to apply Corpus analysis to information captured in databases which generates an ontology. It uses case-based methods to automatically organize cases for periodic review.
The Seare Patent is a process for analyzing healthcare providers' billing pattern to assess utilization patterns of medical services. The method of the invention incorporates a set of statistically derived and clinically validated episodes of care data to be used as a paradigm for analyzing and comparing providers' services for specific diagnoses on medical conditions (col. 18, lines 31-37). The comparison of profiles function provides a comparison between any two profiles sources with attention to variance between them. Some examples include comparing a specific subset of the client's data against either reference tables or the client's profiles, or comparing different subsets of the client's profiles to subsets of reference tables (col. 18, lines 54-61).
The Seare Patent provides a method and system for analyzing historical medical provider billings to statistically establish a normative utilization profile. The method and system of this invention may be implemented in conjunction with a general purpose or special purpose computer system. The first point is important as the present invention is not limited to historical data (this is only one of the independent variables we're recognizing in the process of building an ontology). The second is important because the present invention is an algorithmic/technology focus versus a purely historical focus that any technology may use.
The Zhou Published Patent Application is a system and method for integrating heterogeneous biomedical information. The system is dictated by three orthogonal views (Paragraph [0019]). The method includes ontologies which are used to formally express the medical domain for improved communication of domain concepts among domain components, and to assist in the integration process. Mapping discovery is used to identify similarity between ontologies, determining which concepts and properties represent similar notions either automatically or semi-automatically (Paragraph [0020]). Generative and discriminative models can also be used to support tasks such as disease and disease subclass classification, modeling, and predication (Paragraph [0025]). The use of statistical learning algorithms can shift the burden of feature space manipulation from the user to the machine. Small-sample learning algorithms based on Kernel BiasMap and Rankboosting can be a specific choice of such type of statistical learning algorithms (Paragraph [0026]).
Therefore, there is a significant need to provide an algorithmic method which can be used to generate a medical utilization profile for a patient for facilitating decision making in the medical risk analyses.